Spinkler System - Installation 2012 EXISTING Nursing homes, and hospitals where required by construction type, are protected throughout by an approved automatic sprinkler system in accordance with NFPA 13, Standard for the Installation of Sprinkler Systems. In Type I and II construction, alternative protection measures are permitted to be substituted for sprinkler protection in specific areas where state or local regulations prohibit sprinklers. In hospitals, sprinklers are not required in clothes closets of patient sleeping rooms where the area of the closet does not exceed 6 square feet and sprinkler coverage covers the closet footprint as required by NFPA 13, Standard for Installation of Sprinkler Systems. 19.3.5.1, 19.3.5.2, 19.3.5.3, 19.3.5.4, 19.3.5.5, 19.4.2, 19.3.5.10, 9.7, 9.7.1.1(1)
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Observations: Name: MAIN BUILDING 01 - Component: 01 - Tag: 0351
Based on observation and interview, it was determined the facility failed to provide the proper sprinkler mounting orientation in a room lacking a ceiling, affecting three of five rooms in the basement of the facility.
Findings include:
Observations on April 15, 2025, between 10:43 a.m. and 11:05 a.m., revealed the wrong orientation of sprinkler provided for a basement without a ceiling in the following locations:
a. 10:43 a.m., in the basement telephone room, pendant sprinkler installed in downward position in room lacking ceiling b. 10:50 a.m., in the basement sprinkler room, pendant sprinkler installed in downward position in room lacking ceiling c. 11:05 a.m., in the basement boiler room, pendant sprinkler installed in downward position in room lacking ceiling
Exit interview with the Administrator and Maintenance director on April 15, 2025 at 12:00 p.m. confirmed the improper sprinkler mounting.
| | Plan of Correction - To be completed: 05/30/2025
The sprinkler mounting orientation in the basement telephone room, sprinkler room, and boiler room were inspected by Johnson Controls. Repairs are to be contracted via Johnson Controls to turn sprinklers to appropriate positioning, work to be completed by 5/30/2025. Maintenance will conduct a random inspection of sprinkler heads throughout the building to ensure compliance with NFPA 101 Standard for Sprinkler System Installation. The audits will be conducted for (3) months and will be documented. The Director of Support Services will be responsible for compliance.
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